Hepatic portal venous gas. A review and report on six new cases

Conservative treatment of hepatic portal venous gas resulting from non-occlusive mesenteric ischemia: a case report

A 73-year-old man with severe intellectual disability, malnutrition, and hypoalbuminemia presented to our hospital after experiencing vomiting following dinner. Electrocardiography revealed a sinus rhythm. Plain abdominal radiography showed branching radiolucency in the liver. Abdominal computed tomography (CT) revealed branching gaseous foci of low density in the portal vein and its tributaries, suggesting the presence of hepatic portal venous gas (HPVG). Abdominal contrast-enhanced CT showed a segmental lack of contrast enhancement in the intestinal wall despite the absence of vascular occlusion in the main trunk and branches of the mesenteric artery. The patient was diagnosed with non-occlusive mesenteric ischemia (NOMI) accompanied by HPVG. Peripheral parenteral nutrition, antibiotic treatment, and human serum albumin were administered. The HPVG disappeared approximately 20 h after hospitalization. Intravascular dehydration associated with hypoalbuminemia was considered to be the cause of NOMI; the latter improved through the early correction of dehydration and hypoalbuminemia. The presence of HPVG is usually considered a diagnostic clue in patients with abdominal catastrophe and is associated with high mortality. However, the current case demonstrates the pitfalls of assessing the severity of the underlying condition based solely on the presence of HPVG.

Extensive Aeroportia, Operate or Not to Operate? A Report of a Challenging Case

Aeroportia is the presence of gas in the portal vein. It is considered an ominous radiological sign with poor outcomes. Historically, it was associated with bowel necrosis, and surgery was mandated in all cases. Herein, we present a challenging case of portal venous gas and its management. An 87-year-old male patient, with multiple co-morbidities, presented with abdominal pain. The computerized tomography (CT) scan showed extensive portal venous gas without evidence of bowel ischemia. Initially, he was managed conservatively, but his clinical condition deteriorated. So, an exploratory laparotomy was performed which revealed multiple superficial splenic abscesses covering the surface of the spleen and a pale segment of jejunum with questionable viability. Splenectomy was performed and second-look laparotomy was planned to assess the small bowel viability. Second-look laparotomy revealed dusky discoloration of 30 cm jejunal segment. The affected segment was resected. The patient improved after surgery and was discharged home. In conclusion, aeroportia (portal venous gas) is a radiological entity. The clinical condition of the patient must be kept in consideration to manage the patients optimally. However, if the patient deteriorates, a high index of suspicion for mesenteric ischemia and early surgical intervention are the keys to save the patients' life.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment

BACKGROUND

Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.

AIM

To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.

METHODS

Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.

RESULTS

Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients’ poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.

CONCLUSION

HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients’ prognoses.

Hepatic portal venous gas associated with transcathete cardiac defibrillator implantation: A case report

INTRODUCTION

Hepatic Portal Venous Gas (HPVG) is a rare pathological condition that may be caused by iatrogenic factors.

CASE REPORT

A 66-year-old Chinese male patient with HPVG underwent laparotomy for chronic bowel ischemia. Transcathete cardiac defibrillator was implanted via left subclavian vein for ventricular tachycardia.

DISCUSSION

There are many hypotheses about how gas runs through the intestine into the mesenteric portal venous system. HPVG patients can be improved through comprehensive management. Patients with mesenteric ischemia should be observed in hospital and after discharge, and need surgical intervention if chronic bowel ischemia recurs.

CONCLUSION

This case proves the usefulness of comprehensive management in treating HPVG. Prognosis of HPVG should consider the pathological changes contributing to HPVG.

Hepatic gas: widening spectrum of causes detected at CT and US in the interventional era

The spectrum of causes of hepatic gas detected at computed tomography (CT) and ultrasonography (US) is widening. There are many iatrogenic and noniatrogenic causes of hepatic parenchymal, biliary, hepatic venous, and portal venous gas. Hepatic gas may be an indicator of serious acute disease (infarct, infection, abscess, bowel inflammation, or trauma). In other clinical scenarios, it may be an expected finding related to therapeutic interventions (such as surgery; hepatic artery embolization for a tumor or for active bleeding in acute trauma cases; percutaneous tumor ablation performed with radiofrequency, cryotherapy, laser photocoagulation, or ethanol). In some cases, hepatic gas is an incidental finding of no clinical significance. Familiarity with the expanding list of newer intervention-related causes of hepatic gas detected at CT and US, knowledge of the patient's clinical history, and a careful search for associated clues on images are all factors that may allow the radiologist to better determine the clinical relevance of this finding.

A case of hepatic portal venous gas as a complication of endoscopic balloon dilatation

The development of hepatic portal venous gas (HPVG) is rare but it might be associated with serious disease and poor clinical outcome. Recently, several iatrogenic causes of HPVG have been reported. HPVG as a complication of endoscopic balloon dilatation is a previously unreported event. We experienced a case of HPVG after endoscopic balloon dilatation in a 31 yr-old man with pyloric stricture due to corrosive acids ingestion. The patient was treated conservatively with fluid resuscitation, antibiotics and Levin tube with natural drainage. Five days later, the follow-up CT scan showed spontaneous resolution of HPVG. This case reminded us the clinical importance and management strategy of HPVG. We report here a case of iatrogenic HPVG with a review of relevant literature.

Portal gas in a diabetic patient under pharmacotherapy with an alpha-glucosidase inhibitor: report of a case with emphasis on US findings

Portal gas is relatively rare, and its relation to ischemic bowel diseases has been emphasized. We report the case of a 56-year-old diabetic man under pharmacotherapy with an alpha-glucosidase inhibitor in which portal gas was incidentally detected by ultrasound (US). It showed multiple echo spots moving in the portal vein. Doppler signals confirmed them to be bidirectional and spiky, which immediately led to the diagnosis of portal gas. A change in oral antidiabetic drug caused the portal gas to disappear. We stress the usefulness of US and Doppler US for detecting and diagnosing portal gas. Although detailed analysis of a larger series of diabetic patients under this therapy is needed to draw a definitive conclusion, our observation merits attention. We also briefly review the literature.

Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment

Hepatic portal venous gas (HPVG), an ominous radiologic sign, is associated in some cases with a severe underlying abdominal disease requiring urgent operative intervention. HPVG has been reported with increasing frequency in medical literature and usually accompanies severe or lethal conditions. The diagnosis of HPVG is usually made by plain abdominal radiography, sonography, color Doppler flow imaging or computed tomography (CT) scan. Currently, the increased use of CT scan and ultrasound in the inpatient setting allows early and highly sensitive detection of such severe illnesses and also the recognition of an increasing number of benign and non-life threatening causes of HPVG. HPVG is not by itself a surgical indication and the treatment depends mainly on the underlying disease. The prognosis is related to the pathology itself and is not influenced by the presence of HPVG. Based on a review of the literature, we discuss in this paper the pathophysiology, risk factors, radiographic findings, management, and prognosis of pathologies associated with HPVG.

Flaming portal vein as a new color Doppler sign of portal gas: report of two cases

Portal gas is relatively rare, and the majority of reported cases have shown it to have a close relation to bowel diseases. At present, portal exploration usually begins with color Doppler sonography, and clinicians now possess a good understanding of color Doppler findings of a wide spectrum of portal abnormalities. However, the color Doppler sign we present in this article has not been reported before. We report two cases of ischemic bowel disease in which B-mode ultrasound showed multiple hyperechoic spots moving in the portal vein; the color Doppler appearance was as if the portal vein was on fire (flaming portal vein sign). Knowledge of this simple color Doppler sign helps to improve the diagnostic strategies in patients with portal gas.

Iatrogenic gastric dilatation: a rare and transient cause of hepatic-portal venous gas

Gas in the portal veins is rare and in most cases is associated with serious diseases and poor clinical outcome. A case of gas in the hepatic-portal veins with gastric dilatation, as shown by CT-scanning for abdominal trauma, is reported. The condition was clinically benign and resolved spontaneously. An abdominal CT scan documented the findings.

Portomesenteric venous gas in acute bowel ischemia: report of a case

Portomesenteric venous gas and pneumatosis intestinalis (PI) are rare but important radiographic findings. They are usually discussed separately in the literature and little is known about the clinical importance of their combination in acute bowel ischemia. Abdominal computed tomography (CT) has proven useful for detecting subtle portomesenteric venous gas or PI in the early stages of acute bowel ischemia. Although the CT findings of either portomesenteric venous gas or PI as separate entities are not pathognomonic of bowel infarction, CT evidence of the combination of both these disorders is strongly associated with transmural bowel infarction, especially band-like pneumatosis. We report a case of portomesenteric venous gas combined with band-like pneumatosis, diagnosed based on CT evidence of both findings. We performed an emergency laparotomy for suspected acute bowel ischemia, which was confirmed by the operative findings.

Portal gas in a patient with acute obstructive cholangitis: report of a case with emphasis on US findings

Portal gas is relatively rare, and its relationship to ischemic bowel diseases has been emphasized. We report the case of a 70-year-old woman with acute obstructive cholangitis in whom portal gas was detected by ultrasonography (US) but not by computed tomography (CT). The former showed multiple echo spots moving in the portal vein. Doppler signals confirmed them to be bidirectional and spiky, which immediately led to the diagnosis of portal gas. Immediate appropriate antibiotic treatment and biliary drainage yielded the disappearance of the portal gas. We stress the usefulness of US and Doppler US for detecting and diagnosing portal gas. Our observation suggests that when portal gas is detected by US, the possibility of cholangitis should be included in the differential diagnosis.

Hepatic portal venous gas in ultrasonogram--benign or noxious

The purpose of this study was to investigate and differentiate the characteristics of benign hepatic portal venous gas (HPVG) and noxious HPVG on sonographic images. This study included seven patients (age 65 to 89 y; mean 75 y) with sonograms and computed tomography (CT) images performed within 4-h interval. The sonographic findings of HPVG could be categorized into three patterns: (1) dot-like pattern in two patients; (2) streak-like pattern in three patients; and (3) fruit-pulp-like pattern in two. In the cases of dot-like pattern, it is of a benign transient situation; this phenomenon may be only demonstrated on sonograms but not necessarily on CT. The prognosis is more favorable and any subsequent CT may not be required. In the cases of streak-like or fruit-pulp-like patterns without localized liver lesions (e.g., abscess), it usually indicates a noxious scenario with worse clinical sequelae. We concluded that the identification of sonographic patterns of HPVG might be important to predict patient's outcome.

Early recognition of hepatic portal vein gas on CT with appropriate surgical intervention improves patient survival

Historically, hepatic portal vein gas has been linked with a dismal prognosis. However, in the last 3 decades, identification of hepatic portal vein gas has undergone a transition from late recognition on roentgenograms to earlier identification on computed tomography scan. The 5 patients in this case series were found to harbor hepatic portal vein gas identified using computed tomography scan. Eighty percent of the patients had concomitant pathology identified by computed tomography, felt to be the cause of the hepatic portal vein gas. All patients were taken to the operating room for exploration and resection of the offending pathology. All 5 patients survived. We suggest that early recognition using computed tomography scan, with appropriate operative intervention, improves the chance for patient survival when hepatic portal vein gas is identified.

Intravascular gas as an incidental finding at US after blunt abdominal trauma

PURPOSE

To describe the occurrence and importance of intravascular gas at ultrasonography (US) during the initial examination of patients after blunt abdominal trauma.

MATERIALS AND METHODS

Reports of all abdominal US examinations performed at one institution for blunt trauma from October 1995 through June 1996 were reviewed. The charts of patients with intravascular gas were examined to determine the mechanism of injury, associated findings, and clinical outcome.

RESULTS

A total of 730 patients underwent abdominal US examinations during the 9 months of study; five had intravascular gas demonstrated. Two patients had portal venous gas, one had hepatic venous gas, and two had inferior vena caval gas. Four of the five patients were involved in motor vehicle accidents, and one had been assaulted. In patients in whom follow-up studies were obtained, there was no evidence of intravascular gas at US or computed tomography. No cause was found at imaging or clinical examination.

CONCLUSION

Intravascular gas may occur as a transient incidental finding after blunt abdominal trauma.

Sonographic recognition of pneumatosis intestinalis and portal gas in an 11-months-old infant--case report

Sonography was performed on an 11-month old infant who presented with intestinal obstruction. Pneumatosis intestinalis and portal venous gas were detected in addition to dilated small bowel loops. Preoperative diagnosis of small bowel gangrene was made which was proven at operation.

Adult survival with intrahepatic portal venous gas secondary to acute gastric dilatation, with a review of portal venous gas

The radiological observation of hepatic portal venous gas on plain abdominal radiography, ultrasonography or computed tomography is a highly significant finding. Its cause warrants urgent diagnosis and will usually require surgical management. Current overall mortality rate associated with this sign is 75%. A case of acute gastric dilatation with hepatic portal venous gas in an adult who survived without surgery is presented. Patients having this sign after double-contrast barium enemas with quiescent inflammatory bowel disease have also been reported to survive without surgery.

Massive gas embolism in E. coli septicemia

The case of an elderly women with radiographic evidence of gas within her portal vein as well as the iliac and femoral arteries is presented. The underlying cause proved to be E. coli septicemia. Differential diagnosis and clinical significance of intravascular gas are reviewed.

Meningitis and Brain Abscess Due to Clostridium Perfringens And Clostridium Paraputrificum Following Orbital Trauma

An 8 year old boy developed cerebral abscess and purulent meningitis due to Clostridium perfringens and Clostridium paraputrificum after trauma to the left orbit. The patient made a satisfactory recovery with surgical treatment and antibiotic therapy. A review of the literature revealed that meningitis due to Clostridia is rare and usually related to penetrating trauma, and that penetrating trauma to the orbit is associated with significant central nervous system morbidity.

Hepatic--portal venous gas in adults: etiology, pathophysiology and clinical significance

The roentgenographic finding hepatic--portal venous gas (HPVG) has been reported extensively in the pediatric and radiology literature. The surgical implications and clinical significance have yet to be fully defined. This study reviews the 60 reported cases in the literature and adds four new cases. HPVG appears as a branching radiolucency extending to within 2 cm of the liver capsule. HPVG is associated with necrotic bowel (72%), ulcerative colitis (8%), intra abdominal abscess (6%), small bowel obstruction (3%), and gastric ulcer (3%). Mucosal damage, bowel distention and sepsis predispose to HPVG. The current mortality rate of 75% represents an improvement from previous experience. Analysis of survivors indicates that the finding of HPVG requires urgent surgical exploration except when it is observed in patients with stable ulcerative colitis.

Hepatic--portal venous gas in adults: etiology, pathophysiology and clinical significance

The roentgenographic finding hepatic--portal venous gas (HPVG) has been reported extensively in the pediatric and radiology literature. The surgical implications and clinical significance have yet to be fully defined. This study reviews the 60 reported cases in the literature and adds four new cases. HPVG appears as a branching radiolucency extending to within 2 cm of the liver capsule. HPVG is associated with necrotic bowel (72%), ulcerative colitis (8%), intra abdominal abscess (6%), small bowel obstruction (3%), and gastric ulcer (3%). Mucosal damage, bowel distention and sepsis predispose to HPVG. The current mortality rate of 75% represents an improvement from previous experience. Analysis of survivors indicates that the finding of HPVG requires urgent surgical exploration except when it is observed in patients with stable ulcerative colitis.